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Bouter C, Meller B, Sahlmann CO, Meller J. 99mTc-Besilesomab-SPECT/CT in Infectious Endocarditis: Upgrade of a Forgotten Method? Front Med (Lausanne) 2019; 6:40. [PMID: 30873410 PMCID: PMC6402384 DOI: 10.3389/fmed.2019.00040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 02/11/2019] [Indexed: 12/25/2022] Open
Abstract
Infective endocarditis displays a serious condition with high mortality rates. Establishing a reliable diagnosis can be challenging. This study evaluates granulocyte imaging with 99mTc-Besilesomab-SPECT/CT in order to determine the clinical value of the method and its possible redefinition through the addition of hybrid imaging. The study comprises 26 consecutive patients with suspected infectious endocarditis or prosthetic valve infection that underwent 99mTc-Besilesomab-SPECT/CT in our facility between December 2016 and September 2018. 99mTc-Besilesomab-SPECT/CT images were reviewed by two independent and blinded observers and results were evaluated by transesophageal echocardiography (TEE) and blood culture results as well as by pathological, bacteriological, and clinical findings. Target-to-Background-Ratios were calculated for semi-quantitative analysis. 13/26 patients were in a post-surgical stage. 99mTc-Besilesomab-SPECT/CT was positive in 6 cases. All 6 cases were true positive confirmed by pathological or clinical findings according to the modified Duke Criteria for infective endocarditis. Remaining 19/26 cases were true negative. Target-to-Background ratios were significantly higher in patients that were visually scored positive compared to negative cases. Inter-observer agreement was very good of deciding whether a scan was positive or negative. Sensitivity of 99mTc-Besilesomab-SPECT/CT was 86–100% and specificity was 100%. 99mTc-Besilesomab-SPECT/CT is a useful imaging method for the diagnosis of endocarditis, especially in difficult cases with prosthetic valves or cardiac devices and inconclusive findings in echocardiography. The added value of SPECT/CT was mainly finding and localizing increased uptake at a certain valve, prosthesis, or device cable.
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Affiliation(s)
- Caroline Bouter
- Department of Nuclear Medicine, Georg-August-University Göttingen, Göttingen, Germany
| | - Birgit Meller
- Department of Nuclear Medicine, Georg-August-University Göttingen, Göttingen, Germany
| | - Carsten O Sahlmann
- Department of Nuclear Medicine, Georg-August-University Göttingen, Göttingen, Germany
| | - Johannes Meller
- Department of Nuclear Medicine, Georg-August-University Göttingen, Göttingen, Germany
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Gomes A, Glaudemans AWJM, Touw DJ, van Melle JP, Willems TP, Maass AH, Natour E, Prakken NHJ, Borra RJH, van Geel PP, Slart RHJA, van Assen S, Sinha B. Diagnostic value of imaging in infective endocarditis: a systematic review. THE LANCET. INFECTIOUS DISEASES 2016; 17:e1-e14. [PMID: 27746163 DOI: 10.1016/s1473-3099(16)30141-4] [Citation(s) in RCA: 163] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 05/05/2016] [Accepted: 05/25/2016] [Indexed: 12/19/2022]
Abstract
Sensitivity and specificity of the modified Duke criteria for native valve endocarditis are both suboptimal, at approximately 80%. Diagnostic accuracy for intracardiac prosthetic material-related infection is even lower. Non-invasive imaging modalities could potentially improve diagnosis of infective endocarditis; however, their diagnostic value is unclear. We did a systematic literature review to critically appraise the evidence for the diagnostic performance of these imaging modalities, according to PRISMA and GRADE criteria. We searched PubMed, Embase, and Cochrane databases. 31 studies were included that presented original data on the performance of electrocardiogram (ECG)-gated multidetector CT angiography (MDCTA), ECG-gated MRI, 18F-fluorodeoxyglucose (18F-FDG) PET/CT, and leucocyte scintigraphy in diagnosis of native valve endocarditis, intracardiac prosthetic material-related infection, and extracardiac foci in adults. We consistently found positive albeit weak evidence for the diagnostic benefit of 18F-FDG PET/CT and MDCTA. We conclude that additional imaging techniques should be considered if infective endocarditis is suspected. We propose an evidence-based diagnostic work-up for infective endocarditis including these non-invasive techniques.
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Affiliation(s)
- Anna Gomes
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands.
| | - Andor W J M Glaudemans
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Daan J Touw
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Joost P van Melle
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Tineke P Willems
- Department of Radiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Alexander H Maass
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Ehsan Natour
- Department of Thoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Niek H J Prakken
- Department of Radiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Ronald J H Borra
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Peter Paul van Geel
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Riemer H J A Slart
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Groningen, Netherlands; Department of Biomedical Photonic Imaging, University of Twente, Enschede, Netherlands
| | - Sander van Assen
- Department of Internal Medicine, Division of Infectious Diseases, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Bhanu Sinha
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
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Cascini GL, De Palma D, Matteucci F, Biggi A, Rambaldi PF, Signore A, Mansi L. Fever of unknown origin, infection of subcutaneous devices, brain abscesses and endocarditis. Nucl Med Commun 2006; 27:213-22. [PMID: 16479240 DOI: 10.1097/00006231-200603000-00003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The term 'fever of unknown origin' includes a wide range of conditions that often remain undiagnosed. The possibility of an infection must be promptly diagnosed in order to begin appropriate therapy. Imaging with radiopharmaceuticals, computed tomography, magnetic resonance imaging and ultrasound are the most commonly applied techniques, usually performed in addition to blood tests, biopsies or tissue cultures when required. The lack of comparative studies investigating the accuracy of each radiopharmaceutical for the study of fever of unknown origin was the incentive to perform a meta-analysis of peer articles published between 1981 and 2004 (33 papers) describing the use of nuclear medicine imaging for this purpose. Furthermore, infection of subcutaneous devices, brain abscesses and endocarditis must be considered amongst the causes of fevers of unknown origin. Reviews of 23, 10 and 10 papers, respectively (from 1976 to 2005), were performed on these specific topics. The results may be a useful guide for the choice of the optimal radiopharmaceutical(s) and diagnostic strategy to be applied in each clinical condition and for different aims.
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Becker W, Meller J. The role of nuclear medicine in infection and inflammation. THE LANCET. INFECTIOUS DISEASES 2001; 1:326-33. [PMID: 11871805 DOI: 10.1016/s1473-3099(01)00146-3] [Citation(s) in RCA: 87] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Investigators have used various techniques and radionuclides such as 51Cr and 32P-diisofluorophosphate to label blood cells and to study cell survival. Early studies also used these radionuclides to label human leucocytes for cell survival by in-vitro counting. But external imaging could not be done with these agents. Starting with the use of the gamma-emitting radionuclide (111)In-oxine for in-vitro labelling of phagocytic leucocytes, external imaging became possible. This method was the basis of visualisation of cell distribution within the body. Because an abscess consists primarily of leucocytes, leucocytes labelled with (111)In localise within the abscess and are detectable by imaging. Nowadays other radiopharmaceuticals with other underlying uptake mechanisms are also used to detect inflammatory or infectious foci in patients. Nuclear medicine can be most useful in patients with fever of unknown origin, where a focus has to be defined, or in patients where a lesion is known by clinical symptoms or by a radiological imaging and the differentiation between infection and other pathologies has to be made.
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Affiliation(s)
- W Becker
- Department of Nuclear Medicine, University of Göttingen, Germany.
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Gratz S, Raddatz D, Hagenah G, Behr T, Béhé M, Becker W. 99mTC-labelled antigranulocyte monoclonal antibody FAB' fragments versus echocardiography in the diagnosis of subacute infective endocarditis. Int J Cardiol 2000; 75:75-84. [PMID: 11054510 DOI: 10.1016/s0167-5273(00)00301-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE We performed this pilot study to gain first clinical data of immunoscintigraphy with 99mTc-labelled anti-NCA-90 antigranulocyte antibody Fab' fragments (99mTc-Fab' (LeukoScan((R)))) in endocarditis. PATIENTS AND METHODS 99mTc-Fab' and echocardiography were used in 24 consecutive patients with suspected endocarditis. Nuclear medicine imaging was performed after i.v. injection of 925 MBq 99mTc-Fab' fragments and evaluation was done by region of interest (ROI) technique and visually. RESULTS Seven patients were found to have endocarditis on the basis of the revised Duke criteria, which served as gold standard. Initial scintigraphy was true positive in five patients and false positive in one. In the five true positives, T/B ratios in projection to the heart valve plane (with T/B>/=1.3+/-0.072) were highly suspicious for florid endocarditis. TTE and TEE were true positive in two and in six patients, whereas false positives were seen in two and in four patients. Scintigraphy was positive in four of the five patients with the false negative TTE and negative in the three false positive TEE. Vice versa, TEE was positive in the two patients with false negative scintigraphy. CONCLUSIONS Immunoscintigraphy with 99mTc-Fab' fragments in combination with TEE improves diagnostic accuracy compared with TTE/TEE in patients with subacute infective endocarditis.
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Affiliation(s)
- S Gratz
- Department of Nuclear Medicine, Georg August University, Robert Koch-str 40, 37075, Göttingen, Germany.
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Yi K, Chung J, Kim H, Kim I, Jung H, Kim J, Choi I, Suh P, Chung H. Expression and characterization of anti-NCA-95 scFv (CEA 79 scFv) in a prokaryotic expression vector modified to contain a Sfi I and Not I site. Hybridoma (Larchmt) 1999; 18:243-9. [PMID: 10475238 DOI: 10.1089/027245799315899] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The CEA 79 antibody has been used in bone marrow scintigraphy for the differential diagnosis of skeletal tumors and the evaluation of the bone marrow status of patients with various hematological disorders. The specific localization of radio-labeled CEA 79 antibody in bone marrow depends on its reactivity with NCA-95 (nonspecific cross-reacting antigen-95) present on the surface and in the cytosol of human granulocytes and myelopoietic cells. To make a CEA 79 scFv molecule that would be less immunogenic and more penetrating than the intact mouse immunoglobulin, we constructed a pRSET Sfi I/Not I expression vector. The scFv gene was then excised from a pCANTAB 5 E phage display vector by digestion with Sfi I and Not I and inserted into the pRSET Sfi I/Not I expression vector. Upon transformation of a BL21(DE3)pLysS strain of E. coli, CEA 79 scFv became expressed in inclusion bodies requiring a renaturation process for solubilization. The final yield of CEA 79 scFv was 5 mg per a liter of culture. The refolded CEA 79 scFv exhibited an affinity (Kd = 2.1 x 10(-9) M) equivalent to that of the original CEA 79 antibody (K(d) = 3.3 x 10(-9) M) and the same immunoreactivity to CEA and NCA-95 in Western blots and in immunohistochemical staining experiments.
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Affiliation(s)
- K Yi
- Department of Life Science, Pohang University of Science and Technology, Korea
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A kit of human polyclonal IgG for the diagnosis of infectious processes. J Radioanal Nucl Chem 1999. [DOI: 10.1007/bf02349400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Lipman BT, Collier BD, Carrera GF, Timins ME, Erickson SJ, Johnson JE, Mitchell JR, Hoffmann RG, Finger WA, Krasnow AZ, Hellman RS. Detection of osteomyelitis in the neuropathic foot: nuclear medicine, MRI and conventional radiography. Clin Nucl Med 1998; 23:77-82. [PMID: 9481493 DOI: 10.1097/00003072-199802000-00003] [Citation(s) in RCA: 73] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The diagnostic efficacy of (1) combined three-phase bone scintigraphy and In-111 labeled WBC scintigraphy (Bone/WBC), (2) MRI, and (3) conventional radiography in detecting osteomyelitis of the neuropathic foot was compared. Conventional radiography was comparable to MRI for detection of osteomyelitis. MRI best depicted the presence of osteomyelitis in the forefoot. Particularly in the setting of Charcot joints, Bone/WBC was more specific than conventional radiography or MRI.
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Affiliation(s)
- B T Lipman
- Department of Radiology, Medical College of Wisconsin, Milwaukee, USA
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Becker W. The contribution of nuclear medicine to the patient with infection. EUROPEAN JOURNAL OF NUCLEAR MEDICINE 1995; 22:1195-211. [PMID: 8542906 DOI: 10.1007/bf00800606] [Citation(s) in RCA: 72] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Nuclear medicine imaging of infection has two major indications: (a) the localization of a focus of infection in patients with fever of unknown origin; in this context the radio-pharmaceutical should be highly sensitive whereas specificity is not so important because subsequent biopsy or morphologically based imaging can be performed; (b) the diagnosis of an infection in patients with localized symptoms, for example after surgery, when normal anatomy is absent or when metal implants prevent computed tomography or magnetic resonance imaging. In these latter cases high sensitivity and to an even greater extent high specificity are mandatory to guide further clinical management (conservative or surgical). All radiopharmaceuticals available to date, such as technetium-99m nanocolloids, gallium-67 citrate, indium-111- and 99mTc-labelled white blood cells, 99mTc-antigranulocyte antibodies, and 99mTc-or 111In-labelled unspecific human immunoglobulin, have different biodistributions and different physical characteristics. The absence of physiological uptake in an organ and the radiation exposure of a patient are reasons to use different radiopharmaceuticals in different clinical situations, adapted to the individual circumstances of the patient.
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Affiliation(s)
- W Becker
- Department of Nuclear Medicine, University of Göttingen, Germany
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Morguet AJ, Munz DL, Ivancević V, Werner GS, Sandrock D, Bökemeier M, Kreuzer H. Immunoscintigraphy using technetium-99m-labeled anti-NCA-95 antigranulocyte antibodies as an adjunct to echocardiography in subacute infective endocarditis. J Am Coll Cardiol 1994; 23:1171-8. [PMID: 8144785 DOI: 10.1016/0735-1097(94)90607-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVES This study was performed to assess the clinical value of immunoscintigraphy in subacute infective endocarditis. BACKGROUND Radiolabeled granulocytes can reveal inflammatory lesions. METHODS Using technetium-99m-labeled anti-NCA-95 anti-granulocyte antibodies, planar scintigraphy and single-photon emission computed tomography of the thorax were performed in 72 consecutive patients with suspected endocarditis. Each patient also underwent transthoracic and, if findings were negative, transesophageal echocardiography. RESULTS Thirty-three patients were found to have endocarditis on the basis of clinical criteria (surgical confirmation in 17 patients), and the remaining 39 served as control subjects. Initial scintigraphy was true positive in 26 patients (sensitivity 79%) and false positive in 7 (specificity 82%). Echocardiography was true positive in 29 patients (sensitivity 88%) and false positive in 1 (specificity 97%). Scintigraphy was positive in the four patients with false negative echocardiography, and echocardiography was positive in the seven patients with false negative scintigraphy. Thus, the combination of scintigraphy and echocardiography yielded a sensitivity of 100% and a specificity of 82%. In 10 of the 11 patients with two to three follow-up studies, scintigraphy became negative parallel to clinical improvement, indicating decreasing floridity of the inflammatory process. CONCLUSIONS Immunoscintigraphy in patients with subacute infective endocarditis provides valuable diagnostic information in equivocal echocardiographic findings and may be used to monitor antibiotic therapy.
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Affiliation(s)
- A J Morguet
- Department of Cardiology and Pulmonology, Georg August University, Göttingen, Germany
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Becker W, Goldenberg DM, Wolf F. The use of monoclonal antibodies and antibody fragments in the imaging of infectious lesions. Semin Nucl Med 1994; 24:142-53. [PMID: 8023170 DOI: 10.1016/s0001-2998(05)80228-4] [Citation(s) in RCA: 98] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The advantage of immunoscintigraphy over autologous leukocyte techniques in the imaging of infection is the simplicity of its use compared with techniques that require the isolation of autologous white blood cells. The advantage over 99mTc- or 111In-labeled nonspecific human immunoglobulin is the excellent target-to-background ratio, which results from an endogenous background subtraction with the whole antigranulocyte antibody (99mTc-anti-NCA-95; BW250/183) and a rapid clearance of the antibody using an antigranulocyte Fab'-fragment (99mTc-anti-NCA-90; IMMU-MN3). The whole antibody is helpful for imaging of soft tissue infections, peripheral bone, and abdominal infections. Problems may arise occasionally in regions with normal bone marrow that are caused by human antimouse antibody (HAMA) formation. An infection or the entire extent of inflammation can be proven or excluded only at 24 hours postinjection. In contrast, antigranulocyte Fab'-fragment may have its advantage in an earlier localization of infectious lesions (1 hour) owing to its smaller molecular size and its lower affinity for its epitope. This may be promising in the detection of spinal infections and in infections in regions with the presence of normal bone marrow. Also advantageous is the negligible HAMA response rate. Problems may arise in abdominal infections because of an intestinal excretion of activity as early as 4 hours postinjection in some cases but more usually at 24 hours.
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Affiliation(s)
- W Becker
- Department of Nuclear Medicine of the University of Erlangen-Nuremberg, Germany
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Corstens FH, Oyen WJ, Becker WS. Radioimmunoconjugates in the detection of infection and inflammation. Semin Nucl Med 1993; 23:148-64. [PMID: 8511601 DOI: 10.1016/s0001-2998(05)80095-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Various nuclear medicine techniques are widely used to image foci of infection and inflammation. Among the relatively new radiopharmaceuticals for this purpose are radioimmunoconjugates such as labeled murine monoclonal antigranulocyte antibodies and labeled human polyclonal nonspecific immunoglobulin G. This article reviews some background information, mechanism of action, side effects, biodistribution, kinetics, results of clinical studies, and dosimetry of several radioimmunoconjugates both of murine monoclonal and human polyclonal origin. The efficacy of these agents has been demonstrated in a variety of clinical conditions. Radiolabeled immunoconjugates may emerge as convenient alternatives to the present technique of choice: in vitro blood cell labeling techniques with their inherent problems and risks.
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Affiliation(s)
- F H Corstens
- Department of Nuclear Medicine, University Hospital Nijmegen, The Netherlands
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